Medicare is a health insurance program in the United States aimed primarily at individuals aged 65 and older or with certain medical conditions. It is designed to cover various medical services such as hospital stays, outpatient services, and preventive care. It also covers skilled nursing care in nursing home facilities on a short-term basis, usually for recovery after a hospital stay.
What is a Nursing Home?
A nursing home is a facility where individuals can receive additional care services from nurses or nurses’ aides. They can be residential homes or apartments for people who need assistance with daily activities or for those who prefer not to live alone. Nursing homes can also resemble hospitals or hotels with rooms equipped with beds and baths and common spaces for recreational activities, classes, eating, and relaxing. They generally provide around-the-clock care.
What Does Medicare Cover in a Nursing Home?
Medicare does not cover custodial care in a nursing home, which includes services such as bathing, dressing, eating, and going to the bathroom. As a rule of thumb, if a service doesn’t require a professional degree to provide, Medicare likely won’t cover it. However, Medicare does cover skilled nursing care in a nursing home facility, provided several requirements are met:
- You must have Medicare Part A and have days left in your benefit period.
- You must have had a qualifying hospital stay.
- Your doctor must determine you require daily, skilled nursing care.
- You must receive care at a skilled nursing facility.
- The facility where you receive your services must be Medicare-certified.
- You need skilled services for a hospital-related medical condition or a condition that started while you were in a skilled nursing facility getting help for the original, hospital-related medical condition.
Duration of Coverage
Typically, Medicare Part A may pay for up to 100 days in a skilled nursing facility. The facility must admit the person within 30 days after they left the hospital, and they must admit them for the illness or injury for which the person was receiving hospital care.
Parts of Medicare and Nursing Home Coverage
Medicare Part A covers several services in a nursing home environment, including dietary counseling, nutrition services, medical supplies and equipment, medications, meals, occupational therapy, physical therapy, semi-private room, skilled nursing care, social work services related to needed medical care, and speech-language pathology.
Medicare Part B, which pays for outpatient services like doctor’s visits and health screenings, does not usually cover nursing home stays. Medicare Advantage plans (Medicare Part C) don’t generally cover nursing home care considered custodial care, but some exceptions exist if the plan has a contract with a specific nursing home or organization that operates nursing homes. For Part C, it is recommended to contact your plan provider to understand what services are and aren’t covered under your Medicare Advantage plan.
Medigap supplements, which help cover additional costs like deductibles, can sometimes pay for skilled nursing facility co-insurance. However, they don’t cover long-term nursing home care. Some plans like C, D, F, G, M, and N can help pay for skilled nursing facility co-insurance, while Plan K pays for about 50% of the co-insurance and Plan L pays for 75%.
Medicare Part D provides prescription drug coverage. A person living in a nursing home typically receives their prescriptions from a long-term care pharmacy. If you’re in a skilled facility receiving skilled nursing care, Medicare Part A will usually cover your prescriptions during this time.
What if I Need Long-Term Care?
Medicare does not typically cover long-term stays in a nursing home. If you anticipate needing nursing home care in the near future, most Medicare plans won’t be sufficient unless you purchase a Medicare Advantage plan with a specific agreement with a nursing home. However, these are often exceptions and not the norm, and available options may vary geographically.
Alternatives to Help Pay for Long-Term Nursing Home Care
If you need to transition to long-term nursing home care, there are options outside of Medicare that may help offset some costs:
- Long-term care insurance can help pay all or a portion of nursing home costs. Many people purchase these policies at a younger age, as the premiums usually increase with age.
- Medicaid: This insurance program helps cover costs for low-income households and has state and national programs that help pay for nursing home care.
- Veterans Administration: Those who served in the military may be able to receive financial assistance for long-term care services through the United States Department of Veterans Affairs.
Please note that some individuals may require Medicaid services after they exhaust their personal financial resources paying for long-term care. For more information on how to qualify, visiting the State Health Insurance Assistance Programs network is recommended.
Advantages of Nursing Home Care
Nursing home care often allows a person to live independently without having to engage in home maintenance activities. Many nursing homes provide social activities that enable individuals to maintain friendships and engage in various activities. The ability to receive necessary nursing services and have trained staff on hand can provide comfort for the person and their family.
In conclusion, while Medicare can cover some aspects of nursing home care, it’s primarily designed for short-term skilled nursing care following a hospital stay and doesn’t cover long-term custodial care. It’s crucial to plan ahead and explore all available options if you anticipate needing long-term nursing home care in the future.